This article explores the violence reduction potential in the intersection between health, criminal justice, and development. It emphasizes public health, rule of law, and equality-driven socioeconomic development as principal concerns in preventing violence. In parts of Latin America, violence has become a serious public health and security problem. Prior studies have explored the risk factors associated with violence as well as experiences in its prevention. These studies and existing approaches to violence prevention provide evidence on where to direct attention and build prevention efforts. This article argues for integrated community-driven and national interventions to create cooperative national local linkages and embed international human rights law at the national and local levels. Nations struggling with violence should be encouraged to apply an integrated framework to prevent violence and reinforce human security.

VIOLENCE AND INSECURITY REDUCTION AS PART OF A NATIONAL DEVELOPMENT STRATEGY

Violence negatively affects national development potential. It discourages democratization and rule of law (1), erodes capacities for building social capital, and reduces social and political participation (2). Instead of serving the citizens, state agents and authorities use violence as a means of enrichment and to perpetuate nondemocratic power structures (3). Violence is a threat to essential liberties and human rightsin particular, the right to life without fearand is recognized as a serious public health problem (4). Violence kills more than 1.6 million people a year, mostly in developing countries, and injures many more (5). The health sector that treats these injuries bears the main burden of nonfatal cases of violence. Violence leads to lost production, expanded criminal justice costs, and increased social problems, such as family disintegration, thus undermining development potential (1, 68).

The global average homicide rate in 2000 was estimated at 8.8 (per 100 000 population) (5). Western Europe was the world's safest region, with homicide rates ranging from 0.7 to 2.2. However, in the world's most dangerous regionmiddle- and low-income Americasthe rate was 27.5, three times the world average. Males aged 15 to 29, living in the low- and middle-income region of the Americas had a homicide rate of 89.7 (5), 12 times higher than that for young women in that area.

This article explores the potential for reducing violence by building preventive strategies and tactics for societies with a statistically high risk of violence. This integrated framework aims to mobilize nations struggling with complex violence and insecuritiessuch as postconflict countries and repressive regimes in Central America1 to inscribe systemic and integrated violence reduction approaches in their national development strategy. It seeks to analyze the root causes, risks, and protective factors associated with violence; relevant rights; and obligations; and to encourage both national institutions and local communities to become active participants in a process of change. While the framework is developed with Latin America in mind, we believe it could be applicable in any society with a high-violence environment. This point finds support in the work done by the World Health Organization (WHO), which establishes that many risk factors associated with violencea central point of departure for this workare the same across regions (5). Combining violence prevention approaches (i.e., public health; criminal, restorative, and transitional justice; and service delivery approaches) with the prioritization force (10: p. 23) of the human security approach and the rights-based approach to development, it prioritizes protection and empowerment strategies against insecurity and violence related to three essential sets of human rights:

 -The right to physical and mental health2 (11)  -The right to life3 (12) and freedom from torture4 (13)  -The right to development5 (14)

The framework is applied to the health sector, the criminal justice sector, and the socioeconomic sector as well as the family, the community, and social movements. It emphasizes public health, rule of law, and equality-driven socioeconomic development as essential in violence prevention and addresses the intersection between human security and violence by identifying strategies for at-risk populations. The framework was developed over several years of research and fieldwork within programs supported by the Rehabilitation and Research Centre for Torture Victims (RCT) in Central America. RCT partnerships in Honduras with the Centre for the Prevention, Treatment and Rehabilitation of Victims of Torture and their Families and in Guatemala with The Human Rights Office of the Archbishop of Guatemala (15) havewith development funding from the Danish Ministry of Foreign Affairsworked to reduce torture and organized violence. The organized violence concept was developed by the WHO (16) and is defined in Box 1. Two approaches were used: (1) Applied research involving a systematic literature review on what works in violence prevention, including peer-reviewed research, policy studies, manuals, and publications from international organizations; and (2) systematic enrichment and feedback, undertaken from February 2007 to March 2010, including presentations to stakeholders in Central America and Denmark and discussion of preliminary drafts of the framework.

Before introducing the framework and analyzing its uses and potential, we discuss violence definitions and challenges to violence prevention, key aspects of violence in postconflict and high-violence environments (exemplified with Central America), and existing approaches to preventing violence. Finally, we outline some limitations and perspectives.

DEFINITIONS AND TYPOLOGY POSING CHALLENGES FOR VIOLENCE REDUCTION IN POSTCONFLICT AND OTHER HIGH-VIOLENCE ENVIRONMENTS

The preventive framework addresses interpersonal and collective violence (see Box 1), but we argue that the intersection between them challenges the violence typology, when the intent is to measure the accurate level of each type of violence. Several Central American countries struggle with elevated levels of interpersonal violence, economic and politically motivated collective violence, and the insecurities of postconflict and fragile states (3, 17, 18).

From the early 1960s until the mid-1990s, Guatemala, El Salvador, and Nicaragua experienced a series of internal armed conflicts driven by economic and social inequalities and repressive political regimes and fueled by policies pursued in the region by foreign powers within the mindset of cold war politics. These conflicts also affected Costa Rica and especially Honduras due to armed groups being trained and operating outside the conflict countries and large numbers of persons being displaced (19). The peace processes in the region did not result in real changes in the structural inequalities that ignited the conflicts. An abundance of leftover assault weapons and killing skills created explosive situations with renewed conflict potential and led to protracted armed violence long after the end of formal hostilities (15: p. 140; 20: p. 140).

The "northern triangle" countriesEl Salvador, Honduras, and Guatemalaare among the most violent in the world. In El Salvador, the homicide rate in 2005 was 59.9 per 100 000, in Honduras it was 59.6, and in Guatemala it was 44.2or five to seven times the global average (21). Impunity is the rule rather than the exceptionfor example, with only 2% of homicides brought to justice in Guatemala (21). Migrants, drugs, and guns are in constant transit through the region: "guns are flowing southwards from the USA against the flow of northwards drugs." (22: p. 295). Fight for control of lucrative illegal markets has led to increased violence associated with drug trafficking and related organized crime. The widespread presence of armed groupsorganized state and nonstate actorsposes a genuine threat to the appropriate function of state institutions (17). Organized armed violent crime by youth gangs known as maras is rising in Honduras, El Salvador, and Guatemala, with spillover into Mexico and important causal links to US deportation policies. An estimated 35 000 Salvadorians, 40 000 Hondurans, and 100 000 Guatemalans are members of gangs with a complex hierarchical organization, with aggressive recruitment strategies, and in armed combat for territorial expansion and lucrative drug trafficking. They use extortion and coercion to "sell" security services and "protection" to residents in dangerous urban communities (often densely populated slum areas) that experience failures in public security, creating a climate of distrust, fear, and human insecurity. To blur the situation, corrupt state police forces are known to be accomplices of gangs, while others in "death squads" target youth and gang members with torture and murder to "clean up" violent areas (23: pp. 913).

In such high-violence settings with weak institutions and multifaceted actors of violence and insecurity, it is difficult to distinguish different motives and categories of violence. We argue that available statistics leave immense room for underreporting collective violence, notably state violence mixed with socioeconomic motives. Box 2 further illustrates these points. In spite of differences between the two types of violenceinterpersonal and collectiveand the fact that each type has its particular risk factors, it is encouraging to note that a number of risk factors are of equal importance for both. This fact indicates that certain violence reduction strategies can reduce several forms of violence simultaneously (24: p. 3; 25).

We argue further that state violence damages society more than the number of violations suggests. State violence legitimizes a culture of violence and supports social acceptability of violent conflict resolution, contributing to an escalating cycle of other forms of violence. Preventing state violence and applying links to international human rights law and standards as advocated by the United Nations (26) are therefore considered vital in creating a national violence reduction strategy without disregarding other forms of collective violence (see Box 3).

The failure of democratically elected governments and institutions to deliver security, governance, and social advances poses real risks for fragile democracies. Concurrently, political, social, and economic elites use all means in their power to protect vested interests, as illustrated by the June 2009 state coup in Honduras. The northern triangle has opted for hard-hand zero tolerance security policies in fighting crime and violence, with very poor results. These hardline policies have not led to improved security or to reduced violence, both of which continue to increase (27, 28). Nicaragua has pursued preventive and social policies aimed at risk groups (29: pp. 182183)for example, community and women police, social programs for youths, and social rehabilitation in prisons, resulting in far less violence. Nicaragua's homicide rate is 12 per 100 000, or one-fifth the rate in the northern triangle, despite a shared postconflict setting.

We conclude that cross-border experience exchanges on security and social policies aimed at reducing violence and insecurities are a promising field of regional cooperation. Accurate levels of state violence and other forms of violence need to be identified, however, to reduce the risk of less effective outcomes that may result from violence prevention efforts being directed toward the wrong root causes, perpetrators, risk, and protective factors.

Six approaches are identified here and their principal violence reduction rationale provides the basis for investing in different approaches, or combinations thereof, to reduce violence.

Service-based approaches (24) are activated af-ter an act of violence has taken place, and they aim to reduce the impact of violence on the victims' lives. Service-based approaches reduce violence through deterrenceby documenting human rights violations and creating possibilities for legal prosecution of perpetrators and by international advocacy using documented cases of state violence to embarrass authorities into reducing such violence.

Criminal justice system approaches (CJS) (27) focus on bringing perpetrators to justice after violence has occurred. Evidence-based community police violence reduction programs, though, direct CJS toward before-the-act prevention. CJS are primarily punitive and aim to reduce crime and violence through a combination of deterrence and incapacitation. Taking repeat perpetrators of crime and violence off the streetsthe incapacitation effecthelps prevent further violence and establish rule of law and respect for human rights. The deterrence effect lies in discouraging potential perpetrators from committing similar acts. However, recent experiences applying strictly punitive criminal justice system approaches in the northern triangle have failed to reduce insecurities and violence (see above).

Restorative justice (RJ) and transitional justice (TJ) approaches are another alternative. While both approaches strive for reconciliation between victims and perpetratorsto come to terms with the past and create peaceful coexistencethey seek different, though complementary, types of justice. RJ emerges as an alternative to and criticism of the repressive and retributive character of CJS, is related to ordinary crime in a normal context, and sees punishment as inadequate to reestablish social harmony (9). The RJ notion has been applied to programs with one common element: "offenders doing something constructive to make the world a better place, rather than simply having pain inflicted on them." (30: p. 33). RJ methods include victimoffender mediation, indirect mediation, and court-ordered restitution (e.g., reparation payments) in settings like the adult or youth justice system, schools, and neighborhood policing for community safety (30: pp. 5255). Violence prevention potential is found in RJs' interest in recidivism.

TJ seeks equilibrium between opposing demands for justice and peacethat is, the difficult task of finding the balance between full retributive justice and absolute impunity, often defined by power relations between actors. TJ enters after systematic and widespread violations of human rights in exceptional contexts of transition (from internal war or authoritarian rule) to democracy (9, 15: p. 141). TJ's violence prevention potential is found in its interest in nonrecurrence of the massive violations of the past, applying a wide range of means (truth commissions, memorialization efforts, reparation programs, gender justice, criminal prosecutions of the chief responsible, and security system reforms).

The human rights-based approach to development (HRBA) bridges human rights and development and its essential strength lies in linking dysfunctional and weak national criminal justice systems to international human rights law and standards (Box 4).

In violence prevention, HRBA identifies at-risk populations as rights holders, while national authorities are recognized as duty bearers. HRBA identifies both the entitlements of rights holdersthat is, the freedom to live without fear (of violence) and the obligations of duty bearers (e.g., to respect, protect, and fulfil those rights and freedoms related to violence). It then works in parallel tracks: toward strengthening the capacities of rights holders to make their claims and toward building the capacities of duty bearers to meet their obligations (26).

HRBA provides international standards and norms, fosters participation of vulnerable populations, identifies citizen entitlements and state obligations explicitly, and can improve capacity building and mobilization in national prevention programs and policies. Any committed stakeholder seeking to prevent violence must enter into legitimate dialogue with governments on the rights conferred by international conventions, such as freedom from torture, the right to life, and the right to physical and mental health, when governments (by ratification) have voluntarily undertaken the obligations to respect these rights. (See Boxes 3 and 4.)

Public health approaches to violence prevention (PH) (5, 3133) are intended to integrate efforts to identify and address root causes and risk factors that may produce violence and to plan for evidence-based prevention. PH constitutes before-the-event efforts, in contrast to the service-based and criminal justice approaches. PH is based on the ecological model, which builds on knowledge about risk factors associated with violence. According to the WHO, interpersonal violence is the result of individual, relational, social, cultural, and environmental factors. The model thus explores the relationship between these levels of risk factors and considers interpersonal violence as the outcome of multiple influences on behavior (Box 5) (5).

Human security (HS) is a post-cold-war security concept that embodies a fusion of development6 and security. It represents a shift in perspective away from military and territorial security to prioritizing the security of peoplethe referent object of security is the individual rather than the state (34, 35). HS recognizes that states often threaten rather than protect their own populations, and it stresses personal, community, and political security; safety from repression; and protection from organized violence (36: p. 2; 37: pp. 184185). HS implies two mutually reinforcing strategies that shield people from dangers: protecting and empowering people. HS builds on human rights and democratic principles, enables people actively to participate in governance, and requires the strengthening of democratic institutions to establish rule of law (Box 6) (36). Gasper argues that HS offers solutions to some of HRBA's weaknesses: HRBA needs to understand the division of mandates and phased change, and human rights proponents need to prioritize and tailor suggestions to specific situations. He argues that declarations of normative rights are theoretically grounded in conceptions of values and justice, which are founded on human needs. HS can be seen as an offspring of a needs theory that offers a mindset enabling the required prioritization (10: pp. 1926). In this paper, we applied this mindset to prioritize the three sets of rights mentioned earlier, which are important when engaging in violence and insecurity prevention. The HS entry point for violence prevention is prioritizing and addressing insecurities produced by violence to attain a higher degree of protection and empowerment of populations facing risks and dangers (23, 24, 36).

The main focus, principal methods, and violence prevention potential of the six discussed violence prevention approaches are compared in Table 1. Building on this analysis the preventive framework presented below aims to join normative and value-based entries (represented by CJS, RJ/TJ, HRBA, and HS) and instrumental knowledge and evidence-based entries (moderately represented in CJS but mainly by PH). It unites preventive potentials of before-the-act (as PH and HS) and after-the-act entries (as SB, CJS, and RJ/TJ); identifies at-risk victims, perpetrators, and vulnerable groups; and is intersectoral (as PH, HRBA, and HS) and people centered (as HS). It uses the mutually reinforcing bottom-up and top-down motivational and transformative strategies (like HRBA and HS) as drivers. Thus, it is participation driven through community empowerment and protection driven by developing norms, processes, and institutions to shield against dangers. It is accountability driven by identifying rights holders' entitlements and duty bearers' obligations and by linking CJS to international human rights law. These entries are fused into a systemic frame for analyzing and designing normative, but evidence led, violence reduction strategies and tactics.

FRAMEWORK FOR PREVENTION OF VIOLENCE

The framework advances previous work by connecting approaches and concepts in new ways to reinforce violence reduction potentials. It contains six preventive strategiesthree top-down national protection strategies and three bottom-up community-empowerment strategies (see Figure 1). Each strategy comprises tactics that can be applied independently according to relevance and potential in a given context. Three hypotheses underlie the framework: first, that empowerment and protection strategies are mutually reinforcing; second, that interventions involving all three groups of rights and sectors create synergy; and third, that the more strategies and tactics are applied concurrently, the greater are the possibilities for positive outcomes.

This framework provides examples of already documented risk factors, but implementation requires identifying context-specific, interrelated risk factors at national and community levels for each of the selected groups of rights and sectors. The intent is to identify detailed characteristics of at-risk populations as well as possible interventions to protect and empower these populations.

Figure 1 portrays the framework diagrammatically. We recommend examining the diagram in the following manner: The three rights are listed across the top, from left to right, and define the columns beneath them. The societal areas on which we focus are identified beneath these rights: health sectorpublic health; criminal justice sectorgovernance; and socioeconomic sectorsdevelopment. Top-down protection strategies applicable to state actors are delineated from left to right across the three rights and three societal areas noted above. Bottom-up empowerment strategies are similarly delineated, reading upward from the bottom of the diagram. The objectives of the frameworkreduced violence and reinforced human securityare denoted horizontally across the middle of the diagram, covering the three rights, the three sectors, and the two parallel strategies.

The following analysis pursues two objectives:

 -Presenting documented risk factors associated with violence for each of the selected groups of rights at national and community levels. (The list is far from exhaustive and serves only as an illustrative sample. Risk-factor analysis must be contextualized.)

 -Proposing promising strategies and tactics grounded in reviewed literature. Strategies and tactics that demonstrate results in violence reduction have been selected, or they address well-documented risk factors associated with violence, which require testing for violence reduction potential.

The right to physical and mental health

Protection strategy 1: special protection for vulnerable groups and social (re)integration. This strategy seeks to protect vulnerable populations from violence by reducing risks and incentives related to alcohol, drugs, arms, and gangs and to reduce perpetrators' return to violence after conflict or imprisonment by means of nonrecurrence and social reintegration programs.

Examples of relevant risk factors include availability of alcohol and drugs (5, 38, 39), proliferation of small arms (4042), and gangs. "The failure of public security in rapidly mushrooming slums creates a security vacuum which is increasingly filled by organized gangs that take advantage of readily available weapons and a vast pool of unemployed youth from which to recruit members. This toxic mix of kids, guns, and gangs presents serious human security challenges." (23: p. 12).

Examples of promising tactics include regulating small arms and alcohol and combating organized crime, including enforcing child protection, curbing gang formation and recruitment, and preventing drug trafficking (23: pp. 18, 3842). Prohibition, however, has not shown impressive results probably due to the amount of profit involved. Organized crime related to illegal drug trafficking is leaving a bloody trail of violence in many parts of the worldnot least in Central America and Mexicoand advocates for legalizing such drugs under controlled prescriptions are gaining force. Few contest the violence and crime reduction potential of such strategies, which could create tax revenues while destroying lucrative markets and curbing the associated violence. There is empirical evidence on interventions that reduce recidivism, shielding citizens from repeat perpetrators: "we find no evidence of increased repeat offending with Restorative Justice after violent crime. We also find in some tests, substantial reductions in recidivism after violent crime." (30: p. 68). Meta analysis of functional family therapy (where a therapist worked for three months with a youth in the juvenile justice system and the family) shows that the average program reduced a juvenile's recidivism rate by 18.1% (43: p. 191). Transitional justice aimed at reconciliation and disarmament, demobilization, and reintegration of ex-combatants together with small arms control programs are the main top-down policy instruments in violence prevention after conflicts (20: p. 137).

Empowerment strategy 1: strengthen family cohesion and community resilience. This strategy seeks to strengthen parental supervision and family functions, encourage communities to regain safety in public spaces, strengthen community resilience, and claim integrated municipality-driven violence prevention.

Examples of relevant risk factors include weak family socialization, poor parental supervision, harsh parental physical punishment, parental conflicts, large numbers of children in families, young age of mother, poor family cohesion, single-parent households (5, 24), low empathy during early years and youth (44), domestic violence (either suffering it or witnessing it) (8), and vulnerability and perception of insecurity, which create hopelessness, apathy, and decreased resilience against violence (23, 45, 46).

Examples of promising tactics include interventions during a child's early years, strengthening parental supervision and family functions (44); tactics to promote safe communities, safe schools, and safe public spaces (2: pp. 73119; 47); and promoting local consensus and cooperation (48). Bottom-up municipality-driven policies to prevent armed violence have demonstrated evidence of violence reduction. "Armed violence prevention and reduction programmes launched in municipal centres in Colombia, Mexico, Brazil and Haiti during the 1990s and early 2000s adopted a host of programmes ranging from voluntary weapons collection, temporary weapon carrying restrictions, targeting environmental design in areas affected by acute violence, and focused interventions in at-risk groups and paramilitaries, leading to significant decline in homicidal violence." (20: pp. 14445). Firearms are involved in as much as 80% of homicides in Colombia. A study in two Colombian cities (Cali and Bogotá) showed that a citywide ban on carrying firearms was associated with drastic reductions in homicide rates in both cities, leading to reductions in the homicide rates of 14% in Cali and 13% in Bogotá (40: pp. 1205, 1209). The implications of this study for countries with similar high firearm homicide rates like Honduraswhere firearms are involved in 84% of homicidesis that specific control of firearms may dramatically reduce the number of deaths from violence (41: pp. 430, 433). Research suggests that social capital is a key factor in developing and strengthening urban resilience as an essential conflict and insecurity prevention tool. This tactic combines state building with city building to protect its citizens (23: pp. 20, 21).

Right to life and freedom from torture

Protection strategy 2: accountable and transparent powers. This strategy aims to protect people from violence by strengthening state legitimacy7 to ensure accountability and transparency in judicial, legislative, and executive powers by using people-centered security system reforms, strengthening democratic institutions, and aligning national criminal justice systems with international human rights law. "Effective state security institutions upholding the rule of law and human rights are an essential component for achieving human security, development and governance. They are keys to rebuilding trust and confidence in institutions." (36: p. 63).

Examples of relevant risk factors include partial state failure (17); politicized, poorly managed, unaccountable, and unprofessional security bodies and system (49: pp. 25, 26); illegal groups or structures and hidden powers that sustain violence and impunity (3); and impunity in cases of human rights violations being the rule rather than the exception (21).

Examples of promising tactics include people-centered security system reform (23: p. 11; 36: p. 63); strengthened democratic security-sector governance, including legal frameworks consistent with international law and democratic practice; civil management of accountable security oversight bodies; accountable security forces; institutional cultures within security forces that engender respect for the legal framework; and strengthening responsible institutions to enhance delivery of democratic governance (49: pp. 3035). Ball stresses that for these tactics to be successful, they must strive for national ownership by actively involving all relevant national actors.8

Empowerment strategy 2: organized political participation in decision making. This strategy seeks to reduce violence by empowering people and their communities to participate in democratic local governance and claim community policing and municipality-driven integrated violence prevention. "Democratisation at the local level can empower people to work with local authorities to safeguard their human security . . . and help ensure that local governance mechanisms respond to the needs." (23: p. 22). "Local governance concerns the mechanisms through which the diverse interest of local government, private sector and civil society may be accommodated, and the institutions allowing for cooperative actions to be taken by these actors." (50: p. 14).

Examples of relevant risk factors include failures of public security in urban spaces, parallel and unaccountable private security services (23: pp. 810), poor social integration and low social capital (5), mistrust and social distance between community members and local law-enforcement authorities (24: p. 32; 51), violent conflict resolution, widespread enmity (in which there is no solidarity, no consensus, and no cooperation), and weak local governance (23: pp. 22, 49).

Examples of promising tactics include democratic governance reform meeting international standards but grounded in local ownership (49: p. 31; 50: p. 5), fostering inclusive local citizen participation to demand democratic local governance (50: p. 14), and addressing failures in public security. "Building the capacity for public security provision is at the heart of addressing these problems" paired with community policing (2: pp. 179182; 23, p. 10). Community policing in Bogotá, Colombia, helped cut homicide rates in half within a decade and changed community perceptions of the police from negative to positive. "Efforts to develop more responsive law enforcement have led to innovations such as community policing, in which local residents and police work together over time to establish relationships of mutual cooperation and trust." (23: p. 3). Municipalities represent the level of governance closest to peopleas such, they can be effective focal points for integrating efforts in violence prevention. Municipality-driven approaches offer a promising tactic to reduce violence (2: pp. 211220). "Some municipalities in El Salvador, Nicaragua, Colombia . . . focus on locally defined and sustained action plans and indicators, intersector violence prevention and reduction activities, and efforts gradually to scale up successful activities" and "these interventions also purposefully seek to build up confidence and legitimacy through the deliberate engagement of local actors." (20: p. 145).

Right to development

Two strategies address socioeconomic inequality between groups. "A great deal of evidence shows that when wide economic disparities exist in a society, even a relatively wealthy one, these are accompanied by similar disparities in levels of violence. In turn, these disparities are likely to contribute to greater overall levels of violence in that society than in less inequitable societies." (24: p. 8).

Protection strategy 3: increase socioeconomic equality between groups. This strategy seeks to protect people from tensions and violence caused by social and income inequality between groups by fostering social cohesion (e.g., through tax and land reform), by investing in employment schemes for at-risk young men, and by reorganizing national social programs to address inequalities. In Latin America, it is important to design, test, and evaluate strategies to reduce social and economic inequalities among groups. This could prove particularly relevant and powerful, given that middle- and low-income America currently exhibits the world's most unequal distribution of income and the highest intensity of violence. As the Danish government notes, "Of the 20 countries in the world with most skewed income distribution, 12 of them are situated in Latin America." (52: p. 5).

Examples of relevant risk factors include social and income inequality between groups. A Brazilian study found strong differences in homicide rates across different districts in São Paulo City, and "a coincidence was observed between districts with the lowest socio-economic indicators and those with the highest homicide rates." (53: p. 4). The study concludes: "Economic development and reducing socio-economic inequalities may have an impact on the rates of mortality due to violence." (53: p. 1). Another study from Brazil concludes: "this study provides empirical evidence of the severe and risky situation that youths in low-income urban areas are experiencing in the City of Rio de Janeiro . . . homicides are clustered in the sector of the city that has the highest density of slum residents. The hostile environment and the increasing violence in those communities are understood as consequences of relative inequalities compared with the wider society . . . there is a growing recognition of the need for prevention policies directed at young residents in low-income urban areas. . . . The findings of this study strongly suggest that social policies specifically addressed to these youths, including programs to reduce the harmful effects of relative deprivation, may have an important impact on homicide mortality." (54: p. 849).

Examples of promising tactics include policies for social cohesion, tax reform, and land reform (55); prevention and employment programs focused on youth and specifically young men; and reorganization of national social programs to address inequalities (5, 23, 24: p. 3; 53: p. 1; 54: p. 849).

Empowerment strategy 3: organized active participation in local economies to reduce inequality. This strategy seeks to reduce violence by empowering socially excluded people to participate in the local economy by reducing school dropout rates, enhancing cooperative management and negotiation capacities, and strengthening communities to claim municipality-driven integrated violence prevention.

Examples of promising tactics include promotion of cooperatives, enhanced management capacities for productive projects in local areas, and enhanced negotiation capacity for participation in local budget decisions (48, 56). Tactics targeting high-risk groups should include urban or municipality employment schemes focused on youth and specifically young men (53, 54). Finally, new progressive constitutions with a focus on rights and citizen participation have seen the light in Venezuela, Bolivia, and most recently in Ecuador in September 2008 (57). With their foundation in citizen power, they constitute potential instruments for reform and social change (e.g., addressing violence and inequalities).

Limitations

This paper does not address education, communication, and culture as specific entry points in violence prevention efforts, important as they may be. The authors acknowledge that important knowledge and added value could be gained by a more explicit assessment of these sectors. A few examples of perspectives arising from these limitations are discussed in the next section.

Perspectives on the framework

Although the challenge is in the design and implementation of interventions to reduce violence, most research efforts thus far have focused on delineating risk factors for violence, as opposed to factors that protect against violence (58). While there is violence reduction evidence to support many of the suggested interventions advocated in this paper (see above), some less-noted tactics that have been explored can be classified as "might work" or "promising." These promising tactics address well-documented and important risk factors associated with violence; more research is needed to establish their effectiveness in preventing violence.

As noted, the six strategiesthree protective and three empoweringneed to be sensitive to culture, education, and communication. Research suggests that violence prevention in some cases requires a move away from a masculine power culture that "continually recreates gendered structures that reinforce power and authority as masculine and that confer opportunities and constraints in ways that favor men over women" and needs to promote that authority stems from respect and compassion for others rather than power over others (59: p. 28). Such cultural changes address social dynamics that sustain violencefor example, patriarchal notions of masculinity that value toughness, risk taking, and fighting rather than peaceful conflict resolution (60: p. 1015)and would further strengthen the protection strategy "special protection for vulnerable groups and social (re)integration."

The development of nine core competencies9each comprising detailed learning objectives and jointly aimed at improving the infrastructure needed to practice violence prevention effectivelyrepresents one of the first comprehensive standards for training and assessment for public health professionals interested in broad-based injury and violence prevention (61: p. 604). These standards provide direction for integrating strategic education and communication efforts into the preventive framework. Developing similar standards for criminal justice and other professionals seems equally important.

Availability of resources and sustainability are key issues in violence prevention. The violence prevention framework presented holds the potential to reduce the societal cost associated with violence and thus possibilities to redirect public savings to sustainable development and further prevention. The United Nations Development Programme (UNDP) estimates that violence is responsible for a reduction of 7.3% of gross domestic product in Guatemala and 11.5% in El Salvador (62: p. 63). The UNDP recognizes that the estimated US$2.4 billion lost to violence a year in Guatemala is a very conservative estimate due to the lack of reliable data on violent incidents in the country. However, the amount estimated to be lost is equivalent to more than double the total budgets allocated in 2006 to the Ministries of Health, Education, and Agriculture (62: pp. 6263). Budget and human resource restrictions will at first dictate how many preventive strategies and tactics to focus on in the proposed framework. As economies emerge from the burdens imposed by violence, national and local leaders can direct more public funds to maintain and expand violence prevention programs.

Reducing violence could significantly affect investment, tourism, trade, and economic development, not least by promoting a safer, more attractive, less costly enabling environment for human interaction. By making benefits evident to various stakeholdersthe state, the private sector, nonprofit civil society, and international entitiesalliances can be created or consolidated to eradicate violence. Building inclusive alliances and coalitions requires strenuous effort and will be opposed by certain sectors that use violence to create personal wealth and power.

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26. Office of the United Nations High Commissioner for Human Rights. Frequently asked questions on a human rights-based approach to development cooperation. New York and Geneva: United Nations. 2006. Available from: http://www.ohchr.org/Documents/ Publications/FAQen.pdf. Accessed 16 June 2009. [ Links ]

27. United Nations Office on Drugs and Crime and the World Bank. Crime, violence, and development: trends, costs, and policy options in the Caribbean. Washington, DC, and Vienna: United Nations Office on Drugs and Crime and the Latin America and the Caribbean Region of the World Bank; 2007. [ Links ]

Manuscript received on 11 September 2009. Revised version accepted for publication on 13 February 2010

1 Symmetrical or asymmetrical violence relations help define the complexity in the transitions away from conflict (e.g., Guatemala and El Salvador) and repression (e.g., Honduras) and pose special challenges for postconflict societies: "in stable authoritarian regimes, violence is asymmetrical or vertical, given that the State does not face resistance of an armed actor. There is not an armed conflict, but a mere repression. The transition is then simple; it passes from authoritarianism to democracy. In civil wars, violence is more horizontal and, since States that face an armed conflict are usually authoritarian, the transition is double: from war to peace, and from authoritarianism to democracy" (9: p. 15). However, "simple transition" can go both ways when an authoritarian mind set is still present in a society, as illustrated by the June 2009 state coup in Honduras. 2 "The States Parties to the present Covenant recognize the right of everyone to the enjoyment of the highest attainable standard of physical and mental health." Article 12.1. 3 "Every human being has the inherent right to life. This right shall be protected by law. No one shall be arbitrarily deprived of his life." Part III, Article 6. 4 "No one shall be subjected to torture or to cruel, inhuman or degrading treatment or punishment." Part 2, Article 7. 5 Most importantly for this context: "States should undertake at the national level, all necessary measures for the realization of the right to development and shall ensure, inter alia, equality of opportunity for all in their access to basic resources, education, health services, food, housing, employment and the fair distribution of income. Effective measures should be undertaken to ensure that women have an active role in the development process. Appropriate economic and social reforms should be carried out with a view to eradicating all social injustices." Article 8.1. 6 "The type of development that constitutes the present foundation of human security is more accurately defined as sustainable development." (34: p. 5) 7 "In principle, the state commands the monopoly over the legitimate use of force. Legitimate use of force requires a legitimate state. A legitimate state is characterized by transparency, trust of the government by the governed and accountability. A central problem confronting countries that have experienced or are in danger of experiencing major political violence is precisely that the state has lost its legitimacy in the eyes of some portion of its population. Often the state security bodies have contributed to that loss of legitimacy by their inability to protect people from violence, through their role as perpetrators of that violence or as defenders of an unjust, repressive and corrupt political system. Once a state has lost its legitimacy, it also begins to lose its monopoly over means of violence. . . . When state control over monopoly of violence declines significantly, the state risks decomposition, which only further fragments the sources of violence." (49: p. 27) 8 The relevant actors are the security sector itself, consisting of three bodies: (1) bodies mandated to use force (e.g., armed forces, police, paramilitary forces, gendarmeries, military and civilian intelligence services, secret services, coast guards, customs authorities, and reserve or local security units like national guards and presidential guards); (2) civil management and oversight bodies (president or prime minister, national security advisory bodies, legislature and legislative select committees, ministries of defense, internal affairs, foreign affairs, customary and traditional authorities, financial management bodies like finance ministries, budget offices, financial audit and planning units, and statutory civil organizations like civil review boards and public complaint committees); (3) justice and public security bodies (judiciaries, justice ministries, defense attorneys, prisons, criminal investigation and prosecution services, human rights commissions and ombudsmen, correctional services, and customary and traditional justice systems); (4) nonstate security bodies (liberation armies, guerilla armies, traditional militias, political party militias, private security companies, civil defense forces, and local and international criminal groups; and (5) nonstatutory civil society bodies (professional organizations, including trade unions, research and policy analysis organizations, the media, religious organizations, nongovernmental organizations, and concerned public) (49: pp. 28, 38). 9 Public health significance, data, design and implementation, evaluation, management, communication, stimulating change, continuing education, and best practices in specific topics.